Belsey Fundoplication Technique

Figure 2.7. The total (Nissen) fundoplication is a 360-degree wrap of gastric fundus around the distal esophagus. After complete distal esophageal and proximal gastric mobilization (including division of the proximal short gastric vessels; left panel), the crura are approximated to close the hiatus to a normal caliber (center panel). The proximal fundus is wrapped posteriorly around the esophagus and a portion of the fundus is brought anterior to the esophagus.The two edges are sutured together to create the fundoplication over a large bougie to calibrate the size of the wrap (right panel).

operation through abdominal or thoracic incisions, and the intuitive appeal of a total fundo-plication, led to its rapid acceptance among surgeons for use in patients with severe gas-troesophageal reflux symptoms regardless of whether a hiatal hernia was present.

Beginning in 1949 Belsey began to investigate methods of repairing hiatal hernias and correcting gastroesophageal reflux symptoms. The fourth iteration of his operation, the Belsey Mark IV, consisted of a partial (270-degree) fundoplication performed with two rows of sutures, the latter of which was also brought through the diaphragm to anchor the stomach and the fundoplication within the abdomen (Figure 2.8). This operation was introduced in 1955, and results in >600 patients were reported in 1967 after a median follow-up of almost 5 years.68 Anatomic correction and symptomatic success were noted in 85% of patients. This represented a milestone in the reporting of surgical treatments, in which long-term and complete follow-up as well as objective evaluation of symptoms were used to assess the outcomes of a new operation. Because of its complexity and the perceived need to perform the procedure exclusively through a thoracotomy incision, the Belsey Mark IV operation never gained quite the following that the total (Nissen) fundoplication did.

At about the same time that Nissen and Belsey were developing their fundoplication operations in Europe, Hill was devising a third type of anti-reflux procedure in the United

Belsey Fundo

Figure 2.8. The Belsey Mark IV fundoplication is performed via a thoracic approach. After esophagogastric mobilization, the stomach is sutured to the esophagus 1 cm above the esophagogastric junction encompassing 270 degrees of the esophageal circumference (left panel). The second row of sutures is passed first through the diaphragm,then the stomach, and finally the esophagus, and is brought back through those tissues in reverse order in a U-stitch fashion (center panel).When these sutures are tied, the esophagogastric junction and partial wrap superior to it are anchored below the diaphragm (right panel). Crural repair follows completion of the wrap.

Figure 2.8. The Belsey Mark IV fundoplication is performed via a thoracic approach. After esophagogastric mobilization, the stomach is sutured to the esophagus 1 cm above the esophagogastric junction encompassing 270 degrees of the esophageal circumference (left panel). The second row of sutures is passed first through the diaphragm,then the stomach, and finally the esophagus, and is brought back through those tissues in reverse order in a U-stitch fashion (center panel).When these sutures are tied, the esophagogastric junction and partial wrap superior to it are anchored below the diaphragm (right panel). Crural repair follows completion of the wrap.

States. The posterior gastropexy operation was introduced in 1960, and included a partial fundoplication (180-degree) and a unique technique for anchoring the wrap within the abdomen. The fundoplication was created by using figure-of-8 sutures passed first through the posteromedial region of the gastroe-sophageal junction, second through the arcuate ligament (the superior portion of the aortic hiatus in the diaphragm), third through the anterior portion of the cardia, and finally through the arcuate ligament again (Figure 2.9). As each suture was tied, the pressure in the lower esophageal sphincter was monitored

Surgery Hill Reflux

Figure 2.9. The Hill repair is a partial fundoplication that can be performed through a thoracic or abdominal approach. After crural closure and distal esophageal/proximal gastric mobilization (left panel), the median arcuate ligament overlying the aorta is dissected.A heavy suture is placed through the anterior and posterior gastric remnants of the phrenoesophageal ligament and through the median arcuate ligament (center panel). Three similar sutures are placed, one superior and two inferior, to complete the wrap (right panel). The sutures are tied under tension guided by intraoperative manometry.

Figure 2.9. The Hill repair is a partial fundoplication that can be performed through a thoracic or abdominal approach. After crural closure and distal esophageal/proximal gastric mobilization (left panel), the median arcuate ligament overlying the aorta is dissected.A heavy suture is placed through the anterior and posterior gastric remnants of the phrenoesophageal ligament and through the median arcuate ligament (center panel). Three similar sutures are placed, one superior and two inferior, to complete the wrap (right panel). The sutures are tied under tension guided by intraoperative manometry.

intraoperatively with manometry to achieve a calibrated sphincter pressure.69,70 Long-term results in procedures performed by Hill and his protégés were favorable,with good and excellent results in 85-90% of patients.71 However, the need for intraoperative monitoring of lower esophageal sphincter pressure and the lack of familiarity with the arcuate ligament dissuaded most surgeons from adding this technique to their surgical armamentarium.

Almost simultaneous with the introduction of fundoplication operations, surgical techniques were developed to deal with the problem known as the shortened esophagus. The frequency of its occurrence, and even whether there was such an entity, were (and remain) hotly debated topics. As an example, during the discussion of treatment of short esophagus at the American Surgical Association in 1956, several prominent surgeons all but denied the existence of esophageal shortening.72 Early references to congenitally shortened esophagus, of which most were either type I (sliding) hiatal hernias without peptic stricture or represented Barrett's changes, fomented confusion in the early days of anti-reflux surgery. In the decades before the introduction of effective acid suppression therapy there no doubt was a higher frequency of severe esophagitis and peptic stricture than is evident currently. Collagen deposited as part of these conditions underwent cicatricial contraction, shortening the esophagus and drawing the cardia into the mediastinum.

Conservative management of the shortened esophagus almost always failed, and, during the 1940s and 1950s, esophageal resection was the mainstay of therapy. In response to this, in 1956 Collis73 introduced an operation that did "not disorganize the patient's digestive apparatus too much and which [was] easily tolerated by even a frail and aged person." He extended the esophageal tube using the lesser curvature of the stomach, which enabled him to create an acute angle between the gastric fundus and the neoesophagus, a necessary condition of anti-reflux surgery, in his opinion (Figure 2.10). Collis74 was not enthusiastic about the long-term results of the operation, because reflux symptoms were only partially controlled and 30% of patients had unsatisfactory outcomes. However, realizing the potential of this technique for extending the utility of standard fun-

MANAGING FAILED ANTI-REFLUX THERAPY

Belsey Fundoplication 360

Figure 2.10. A lengthening gastroplasty originally described by Collis is useful when combined with fundoplication for managing the short esophagus.In patients with shortening and a hiatal hernia (left panel) the esophagus and stomach are mobilized. If an adequate length of intraabdominal esophagus cannot be achieved, a lengthening procedure is performed. After inserting a large bougie across the esophagogastric junction, a linear cutting stapler is fired parallel to the lesser gastric curvature alongside the bougie to extend the esophageal tube (center panel).The fundus is then wrapped around this neoesophagus to establish an intraabdominal fundoplication (right panel).

Figure 2.10. A lengthening gastroplasty originally described by Collis is useful when combined with fundoplication for managing the short esophagus.In patients with shortening and a hiatal hernia (left panel) the esophagus and stomach are mobilized. If an adequate length of intraabdominal esophagus cannot be achieved, a lengthening procedure is performed. After inserting a large bougie across the esophagogastric junction, a linear cutting stapler is fired parallel to the lesser gastric curvature alongside the bougie to extend the esophageal tube (center panel).The fundus is then wrapped around this neoesophagus to establish an intraabdominal fundoplication (right panel).

doplication operations, Pearson75 was the first to combine the Collis gastroplasty with the Belsey Mark IV technique for management of peptic stricture with esophageal shortening. His group subsequently extended the indications for use of this technique to recurrent hiatal hernia, severe esophagitis without stricture, and reflux problems associated with motor disorders.76 Having experienced less-than-satisfactory outcomes using the Collis-Belsey technique, Orringer and Sloan77 introduced the Collis-Nissen procedure in 1978. Use of an uncut gastroplasty combined with fundoplication for complicated reflux problems was subsequently reported.78-80 The conventional and uncut gastroplasties combined with fundoplication are now standard elements of the armamentarium of many surgeons for managing problems of reflux and large hiatal hernia.

Minimally invasive surgical techniques, primarily laparoscopic methods, were introduced for anti-reflux procedures in 1991.81,82 These techniques rapidly captured the imagination of surgeons and the attention of the public. Within a short time the vast majority of first-time fun-doplication procedures were being performed laparoscopically. The low rate of complications and long-term physiologic and quality-of-life outcomes that approach those of open fundo-plication surgery have confirmed the initial enthusiastic response to these operations.83-88 Costs to society are reduced because of the

HISTORY OF MEDICAL AND SURGICAL ANTI-REFLUX THERAPY

rapid postsurgical recovery experienced by these patients.89,90 The success has been so impressive that the algorithm of GERD management has changed in the minds of some physicians. Many more patients now undergo laparoscopic fundoplication than would previously have qualified for open fundoplication; in North America and Europe, there has been at least a threefold increase in the frequency of fundoplication operations.91-93

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Responses

  • Leonardo
    What is belsey fundoplication?
    3 years ago
  • anselma
    What is the icd10pcs for a Belsey fundoplication?
    2 years ago
  • monika
    What is belsey operation?
    2 years ago
  • mentha whitfoot
    What is Belsy's fundoplication?
    1 year ago
  • Arttu
    What is belseys fundoplication?
    11 months ago
  • drogo
    What determines if nissen; belsey; dor or toupt fundaplication is used?
    6 months ago
  • Regolo Padovano
    What is a modified belsey fundoplication?
    2 months ago

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